Provider Demographics
NPI:1053666818
Name:CHANTHALANGSY, JUDY (OD)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:
Last Name:CHANTHALANGSY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 HUNTING HOUND LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-1855
Mailing Address - Country:US
Mailing Address - Phone:815-997-0164
Mailing Address - Fax:
Practice Address - Street 1:6560 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2545
Practice Address - Country:US
Practice Address - Phone:815-997-0164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1888DT152W00000X
IL046.011481152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000783972OtherANTHEM
KY7100209960Medicaid
KYK051610Medicare PIN